https://s3.amazonaws.com/omeka-net/13418/archive/files/87319ec7ae4275945bdcb8cfd2dec6a8.pdf?AWSAccessKeyId=AKIAI3ATG3OSQLO5HGKA&Expires=1592438400&Signature=gILDL92IDtypQFK83QPRmZb16HI%3Df286b1e9364cdf997339a39e874135e1PDF TextTextWhat Can We Learn from No-Harm Events and Near Misses in Pathology? A Review of 244 Cases.
Yigu Chen MPH, PMP; Gina McCormack; Yael K. Heher MD, MPH, FRCP(C)
Beth Israel Deaconess Medical Center, Harvard Medical School, Department of Pathology
Results
Introduction/Problem
Harmful pathology errors typically undergo systematic review for root causes
in order to seek out opportunities for improvement. However, non-harmful
events including minor errors, near misses, and unsafe conditions are far
more frequent and undergo minimal to no systematic review. Harmful errors
and near misses often share root causes and the difference between the two
can be due to chance alone.
Despite this, non-harmful events and near misses rarely get reported and do
not undergo review. If studied, these events offer an opportunity for learning
and risk reduction for pathologists before serious patient harm occurs.
Design
 A hospital-wide Outlook mailbox was created to solicit information on
laboratory incidents not submitted to the hospital incident reporting system.
 A multidisciplinary team was established including quality, operations,
clinical, and educational leadership to review and manage incidents
weekly.
 Incidents were classified by:
 Eindhoven error classification model by severity
 Error type
 Laboratory and testing phase
 Root cause
 A VBA-programed Excel spreadsheet dashboard served as a hub for
documentation and to track resolution progress.
Lab Phase
Error Type
Root Causes
Testing issue - delay
27, 13%
18, 8%
7, 3%
44, 21%
122, 59%
Other
23
21
Labeling and collection issue
53, 25%
Post-Analytic
26
Reporting issue
35, 17%
Analytic
Specimen processing - mishandled
Ordering issue
85, 41%
Pre-Analytic
37
21
Testing issue - result
Temporary
Harm
27, 13%
Human-based root cause
Organizational-based root cause
Technical-based root cause
Involved at least two levels of root causes
Unable to determine root cause
Near Misses
Unsafe
Conditions
16
21 (10%)
51 (24%)
No-Harm Events
137 (66%)
 244 incidents were reported hospital-wide from May 2016 to August 2017. 35 incidents were excluded as they were
not considered patient safety incidents following review.
 In response to these findings, we have initiated 32 changes in procedures, workflows, and information systems to
prevent similar incidents from recurring.
 By August 2017, 200 (96%) cases were investigated and addressed with an average turnaround time of 3 weeks.
Conclusion
Non-harmful pathology errors and near misses offer critical opportunities for risk reduction and learning. By establishing a
user-friendly reporting mechanism and regular local review and tracking, we were able to understand and address
systems vulnerabilities before patient harm ensued.
For more information, contact:
Yigu Chen, Beth Israel Deaconess Medical Center
�Dublin CoreThe Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.TitleA name given to the resourceSilverman SymposiumDescriptionAn account of the resourceEach year the Silverman Symposium poster session offers BIDMC staff and affiliates the opportunity to share experiences and learn about efforts to improve Quality and Safety.DateA point or period of time associated with an event in the lifecycle of the resource2018Silverman PosterPrimary ContactIf you would like more information about this project, contact this person. Make email address clickable.Yigu Chen (<a title="ychen17@bidmc.harvard.edu" href="mailto:ychen17@bidmc.harvard.edu">ychen17@bidmc.harvard.edu</a>)DepartmentAny departments listed on the poster or identified in the spreadsheet.Pathology
Healthcare Quality and Patient SafetyProject TeamYigu Chen
Gina McCormack
Yael K. HeherBIDMC LocationThe BIDMC location where the poster team resides if identified in spreadsheet. If not identified, choose BIDMC.BIDMCDublin CoreThe Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.TitleA name given to the resourceWhat Can We Learn from No-Harm Events and Near Misses in Pathology? A Review of 244 Cases.DateA point or period of time associated with an event in the lifecycle of the resource2018FormatThe file format, physical medium, or dimensions of the resourcepdfSafety